What is the recommended treatment for a patient with a low testosterone level of 115 ng/dL?

Testosterone Replacement Therapy for Level of 115 ng/dL

Testosterone replacement therapy is strongly recommended for a patient with a testosterone level of 115 ng/dL, as this value falls significantly below the normal range of 300-950 ng/dL and indicates testosterone deficiency requiring treatment. 1, 2

Diagnosis Confirmation

• A testosterone level of 115 ng/dL meets the diagnostic criteria for testosterone deficiency, which is defined as:

  • Total testosterone consistently <300 ng/dL on at least two separate morning measurements 1
  • Presence of symptoms/signs associated with low testosterone 1

• Before initiating treatment, confirm the diagnosis with:

  • A second morning testosterone measurement to verify the low level 1, 2
  • Assessment of luteinizing hormone (LH) to differentiate between primary and secondary hypogonadism 2

Treatment Approach

Initial Treatment

1. Start with testosterone replacement therapy at 40.5 mg applied topically once daily in the morning to shoulders and upper arms 3
2. Monitor pre-dose morning serum testosterone concentration at approximately 14 and 28 days after starting treatment 3
3. Adjust dosage based on serum levels:
   • If >750 ng/dL: Decrease daily dose by 20.25 mg
   • If 350-750 ng/dL: Continue current dose
   • If <350 ng/dL: Increase daily dose by 20.25 mg 3

Treatment Options

• Topical formulations (gels, patches): Applied daily, provide steady testosterone levels 2, 3
• Intramuscular injections: Testosterone cypionate or enanthate administered every 1-2 weeks 2
• Long-acting injections: Testosterone undecanoate can be administered quarterly 2

Monitoring

• Measure testosterone levels 2-3 months after treatment initiation and after any dose change 2
• Once stable, monitor every 6-12 months 2
• Regular monitoring should include:
  • Total and free testosterone levels
  • Hematocrit/hemoglobin (baseline, 3-6 months, then annually)
  • PSA (for men >40 years)
  • Assessment of symptom improvement 2, 3

Contraindications and Precautions

Testosterone therapy should not be used in men with:

• Breast or prostate cancer
• Desire for current or future fertility (if using traditional testosterone therapy)
• Hematocrit >50%
• Severe untreated sleep apnea
• Severe lower urinary tract symptoms
• Uncontrolled heart failure 2

Special Considerations

• For patients with cardiovascular disease, delay TRT for 3-6 months after acute cardiovascular events 2
• For patients interested in fertility preservation, consider alternative treatments or sperm banking before initiating therapy 2
• For patients with pre-existing prostate conditions, careful monitoring is essential 2, 3

Potential Benefits and Risks

Benefits

• Improved sexual function
• Enhanced sense of well-being
• Increased lean body mass
• Decreased body fat
• Increased bone density 2

Risks

• Increased prostate specific antigen
• Mood swings
• Hypertension
• Increased red blood cell count
• Skin irritation at application site
• Gynecomastia
• Potential for blood clots 2

A testosterone level of 115 ng/dL is significantly below the threshold of 300 ng/dL and warrants treatment to address symptoms and prevent long-term complications associated with untreated hypogonadism.